Inter-scalene ultrasound guided nerve block in ED

Date First Published:
November 14, 2016
Last Updated:
November 14, 2016
Report by:
JIa Song , F2 (Guys and St Thomas' Hospital )
Search checked by:
Jia Song, Guys and St Thomas' Hospital
Three-Part Question:
in [ patients needing shoulder reduction ] is [ Inter-scalene ultrasound guided nerve block done by emergency physicians in ED] offer better [ analgesia and clinical outcomes]
Clinical Scenario:
a patient presenting to A&E with simple shoulder dislocation. Should they receive a USS guided interscalene block or a procedural sedation for the joint reduction
Search Strategy:
Athens/Ovid search
'interscalene block' OR 'interscalene block shoulder dislocation'
and ' emergency'
Outcome:
Blaivas, M., Adhikari, S. & Lander, L. A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department. Acad. Emerg. Med. Off. J. Soc. Acad. Emerg. Med. 18, 922–927 (2011).

Blaivas, M. & Lyon, M. Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED. Am. J. Emerg. Med. 24, 293–296 (2006).

Bhoi, S. et al. Feasibility and safety of ultrasound-guided nerve block for management of limb injuries by emergency care physicians. J. Emerg. Trauma Shock 5, 28–32 (2012).

Bhoi, S., Chandra, A. & Galwankar, S. Ultrasound-guided nerve blocks in the emergency department. J. Emerg. Trauma Shock 3, 82–88 (2010).
Relevant Paper(s):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department Blaivas, M., Adhikari, S. & Lander 2011 USA 42 ED patients presenting with shoulder dislocation

Inclusion criteria: >18 yrs old
Exclusion: known local anesthetic allergy, hemodynamic instability, resp distress, altered mental status
21 randomized to US, 21 to sedation.
Prospective randomized study (1+)
Length of stay (primary outcome Sedation = 177.3 (+/-37.9), US = 100.3 (+/-28.2). P <. 0001 No blinding

No measurement of other variables that might affect length of stay (e.g. time to x-ray)

Convenience sample design (i.e. no all that presents)

Single center study
One-on-one health provider time (min Sedation= 47.1 (+/-9.8), US = 5 (+/-0.7). P<.000
Pain experiences during reduction (median) Sedation = 0 (0-4), US= 0 (0-3). P=.9275
Patient satisfaction Sedation = 8.2 (+/-1.3), Us= 8.3 (+/-1). P=.7990
Complication (hypotension, hypoxia) No difference p=.49
Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED. Blaivas, M. & Lyon, M 2006 USA 4 patients cases needing shoulder reduction, where conscious sedation was not possible
case reports (level 3) Complete anesthesia and muscle relaxation allow comfortable reduction obtained in all cases,1 case of temporary recurrent laryngeal nerve palsy V small numbers

No statistical comparison

Total length of stay not reported

Level of expertise and training of ED physician not reported
Bhoi, S. et al. Feasibility and safety of ultrasound-guided nerve block for management of limb injuries by emergency care physicians Bhoi, Chandra& Galwankar. 2010 India 8 patients over period of 3 weeks

Various specialty doctors including ED residents assigned to ED
Case report (3)
If US guided upper and lower extremity peripheral nerve blockage were feasible in ED setting Different patients with different injuries, complexities Different specialty and grade of trainee Different patients with different injuries, complexities

Different specialty and grade of trainee
Ultrasound-guided nerve blocks in the emergency department Bhoi, S., Chandra, A. & Galwankar, S. 2010 India 50 patients (7-80 yrs) with limb injury needing procedural sedation

Various specialty doctors including ED residents assigned to ED
Prospective observational study (2-)
% of cases completed without rescue analgesia Median reduction in pain (primary)* None; Reduction of 7.44 (p=.00001 Observational
No blinding
No control
* 2nd outcome: complication immediate or late at 3month none. Median procedure time – 9min, median reduction of pain 5min
A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department Blaivas, M., Adhikari, S. & Lander 2011 USA 42 ED patients presenting with shoulder dislocation

Inclusion criteria: >18 yrs old
Exclusion: known local anesthetic allergy, hemodynamic instability, resp distress, altered mental status
21 randomized to US, 21 to sedation.
Prospective randomized study (1+)
No blinding

No measurement of other variables that might affect length of stay (e.g. time to x-ray)

Convenience sample design (i.e. no all that presents)

Single center study
Author Commentary:
1) US- guided interscalene nerve block for shoulder dislocation

Blaivas, Adhikari & Lander (2011):

Training received probably more than an average ED physician
Specialized training in USS regional anesthesia
- (2 hour didactic course + hands on training. All at least 2 year experience in US. Each preformed at least 10 interscalene block before)
Clear inclusion and exclusion criteria. All subjects presented with simple dislocation.
Might not be suitable for more complex injuries


Clinical relevance:
US guided interscalene nerve block appear to have similar effectiveness and safety as traditional method

Cost effectiveness:
US guided interscalene nerve block appear to offer speedier recovery time and require less personnel resource


2)Can emergency doctors be trained to perform this technique effectively and safely?

Blaivas & Lyon, 2006
Level of expertise and training of ED physician not reported

Blaivas, Adhikari & Lander, 2011
Specialized training in USS regional anesthesia (2 hour didactic course + hands on training)
All at least 2 year experience in US. Each preformed at least 10 interscalene block before)

Bhoi, Chandra & Galwankar (2010)
Training seminar on US guided upper an lower peripheral nerve block
2/8 were anterior scalene block for shoulder dislocation. both reported complete anesthesia, dischaged after 1h observation

Bhoi et al (2012)
One hour diactic session and practice on live model
One week practice for of nerve identification under superviion.
Minimum of 5 US- guided nerve blocks on nerve model (Blue phantom
24% brachial plexus block 13 shoulder reductions



Bottom Line:
US- guided interscalene nerve block can be safely and effectively performed by emergency physicians with adequate training.
For simple Shoulder dislocation it had similar clinical effectiveness and safety as traditional method, with the added benefit of a speedier recovery time and less personnel resource.


References:
  1. Blaivas, M., Adhikari, S. & Lander. A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department
  2. Blaivas, M. & Lyon, M. Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED.
  3. Bhoi, Chandra& Galwankar. . Bhoi, S. et al. Feasibility and safety of ultrasound-guided nerve block for management of limb injuries by emergency care physicians
  4. Bhoi, S., Chandra, A. & Galwankar, S. . Ultrasound-guided nerve blocks in the emergency department
  5. Blaivas, M., Adhikari, S. & Lander. A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department